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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,-, <br /> 5 7300 CHEVRON WAY, DEXON, CA 95620 <br /> H 1-800-727-2879 <br /> 1 <br /> P WWW.WORLDOILCORRCOM <br /> E TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER # ROUTE#] TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING!MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH REC'D: _ CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE— <br /> OTHER:----- <br /> DESIGNATED <br /> ODEOTHER: —DESIGNATED TSDF: <br /> ALTERNATE TSDF: — <br /> DRUMS PIU: EMPTY DRUMS: FACILITY:_ BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> #1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 ppm.and the waste does not contain any PCBs.I have <br /> compiled with the requirements or the applicable California used oil management regulations to determine this is true.I agree to accept the additional charges for the disposal of this waste it <br /> the Information I have provided about this waste is incorreol <br /> L #2 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional <br /> charges for the disposal of this waste If the Information I have provided about this waste Is incorrect <br /> n #3)This wnste is from a tank which collects waste oil from household"do-it-yourself"(DIY)andlor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oit contained In my DIY1 CESQG collection lank Is Soley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.I agree to accept the additional charges for disposal of this waste it the Information I have provided about this waste Is Incorrect <br /> (All generators/customers MUST read the following text <br /> I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicaily practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. <br /> This Individual signing in the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that customer shall abide <br /> by the Standard Terms and conditions on the reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site spe6fic or consoildated)are subject to an EPA Fee. These tees cover the EPA passthrough fee and administration <br /> of the eManlfeat program. These fees vary based on Manifest type. Applicable fees will appear on your billing Invoice. <br /> Customer Signature Date Driver Signature Date <br /> r <br /> Print Name Print Driver Name <br />